|
i �
<br /> Print Form
<br /> WATER RESOURCE PERMIT APPLICATION FORM
<br /> Use this form to notify/apply to the Minnehaha Creek Watershed District(MCWD)of a proposed project or work which may fall within
<br /> their jurisdiction.Fill out this form completely and submit with your site plan,maps,etc.to the MCWD at:
<br /> 15320 Minnetonka Blvd.Minnetonka,MN 55345.
<br /> Keep a copy for your records.
<br /> YOU MUST OBTAIN ALL RE UIRED AUTHORIZA'TIONS BEFORE BEGINNING WORK.
<br /> 1. Name of each properry owner: L;,tl�,., Gr;c'�� r�����u�R,�.�.,} C� ��, u-c..
<br /> Mailing Address: �.C�. 13ox �{55� City: `j��h� Pwl State:�� Zip: 55 t u�i
<br /> Email Address: � v��1�...���.�.V.a���� w��r,c� .�o,,►,Phone: (,IL•56�t •3`t�(� Fax:
<br /> 2. Property Owner Representative Information(not required) (licensed contractor, architect, engineer, etc...)
<br /> Business Name: C�vC. (..a�.s1,n,�-��,r.,1..�.C... Representative Name: Clnr�s C�ae•-�
<br /> Business Address: City: State: Zip:
<br /> Email Address: cc�.s e.�@ c�•�t w�n►sTrt�c'rcw�n.aa� Phone: (,IZ-353- �l3 Fax:�iz-�z.5- �80�
<br /> 3. Project Address: '�t�4 K��4�u«>d S2�,d City: ��„o
<br /> State: IN� Zip: 553(��1 Qtr Section(s): Section(s): Township(s): Range(s):
<br /> Lot: 3Z Block: Subdivision: �;�ln���� L4\cQ, vti�Y,�►��„�l�s PID: o�- �tl•Z3•�y• ��c�
<br /> 4. Size of project parcel (square feet or acres): I1,��`� s5. Pk
<br /> Area of disturbance(squaze feet): �5�� Volume of excavation/fill (cubic yards):�3
<br /> Area of exisring impervious surface: Z.�5 Area of proposed impervious surface:-Z�l�'G�zy(,C'
<br /> Length of shoreline affected (feet): _ �S Waterbody (&bay if applicabie): ($
<br /> 5. Type of permit being applied for(Check a11 that apply):
<br /> 1� EROSION CONTROL ❑ WATERBODY CROSSINGS/STRUCTURES
<br /> ❑ FLOODPLAIN ALTERATION ❑ STORMWATER MANAGEMENT
<br /> ❑ WETLAND PROTECTION ❑ APPROPRIATIONS
<br /> ❑ DREDGING ❑ ILLICIT DISCHARGE
<br /> ❑ SHORELINE/STREAMBANK STABILIZATION
<br /> 6. Proj ect purpose(Check all that apply):
<br /> � SINGLE FAMILY HOME � MULTI FAMILY RESIDENTIAL (apartments)
<br /> ❑ ROAD CONSTRUCTION ❑ COMMERCIAL or INSTITtJTIONAL
<br /> ❑ UTILITIES ❑ SUBDNISIONS (include number of lots)
<br /> ❑ DREDGING ❑ LANDSCAPING(pools,berms,etc.)
<br /> ❑ SHORELINE/STREAMBANK STABILIZATION ❑ OTHER(DESCRIBE):
<br /> 7. NPDES/SDS General Stormwater Permit Number(if applicable):
<br /> 8. Waterbody receiving runoff from site: �,.��o�, k�e,,��::n��,
<br /> 9. Project Timeline: Start Date: 1�j3�(�'� Completion Date: �1(3n I�5
<br /> Permits have been applied for: City �County �MN Pollution Control Agency �DNR �COE �
<br /> Permits have been received: City—�County—�MN Pollution Control Agency—�DNR-�COE—�
<br /> By signing below,I hereby request a permit to authorize the activities described herein.I certify that I am familiaz with MCWD
<br /> Rules and that the proposed activity will be conducted in compliance with these Rules. I am familiar with the information
<br /> contained in this application and,to the best of my knowledge and belief,all information is true,complete and accurate. I
<br /> understand that proceeding with work before all required authorizarions are obtained may be subject to federal,state and/or local
<br /> a�ninistrarive,civil and/or criminal penalties.
<br /> ,
<br /> ��, a , , ^ ��
<br /> , :, ,
<br /> i .1�� .��..- t J�1°��..�.� � .�`..nrw,n�t.rv� �:�..� '��" ��
<br /> Signature of Each�Property Owner �1•t�V�..,��--- Date
<br />
|